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When Rani Kalyan Parad, a 26-year-old woman from the western Indian state of Maharashtra, learned that she was pregnant with her first child four years ago, she was overjoyed. Nine months later, when her son arrived, the elation turned into her biggest heartache. The boy weighed a total of 2.5 pounds — less than half the low birth weight defined by the World Health Organization (WHO) — had difficulty breathing, and within three days, succumbed. Parad was left battling for her life too.
“There were many complications in the pregnancy: My hemoglobin and nutrition levels were particularly low. But I didn’t know this then,” says Parad, who works as an agricultural laborer in Khojewadi village for a daily pay of INR 200 ($2.80). “During those nine months, I hadn’t had a single medical checkup. The closest hospital was in the city of Aurangabad, more than 16 miles away. One visit meant losing out on a day’s wages as well as costs of at least INR 2000 [$28].”
According to UNICEF, an estimated 800 women die of pregnancy-related causes across the world every day, and 20% of these women are from India. A WHO report from 2015 pegs the number of annual maternal deaths in India at 45,000, while the situation is much worse for newborns: 750,000 neonates (aged 0 to 28 days) die in India every year, the highest for any country in the world. Rural India is responsible for a disproportionately higher number of such casualties owing to lack of access to proper health care.
In a bid to control maternal and neonatal mortality rates in rural India, many technology-based solutions have emerged in the past few years. This trend to leverage technology to ensure safer pregnancies is comprehensive. As of March 2019, with 560 million Indians online, the South Asian country has the second-highest number of internet users in the world. According to a digital adoption and internet trends report from 2018, rural India alone has more than 250 million internet users and is expected to witness double-digit growth for the next few years, and will “continue to drive internet adoption in India.”
Aparna Hegde, founder of ARMMAN, a Mumbai-based nonprofit organization, says technology has made it possible for the several public health programs launched by the Indian government to reach a wider audience. In 2008, ARMMAN launched mMitra, a free mobile voice call service, which sends timed and targeted preventive care information on maternal and infant care to expecting and new mothers in their chosen language: Hindi, Marathi, Kannada, or Gujarati. The service has been used by 2 million women across nine Indian states so far.
The foundation of mMitra lies in the “three delays model” identified by ARMMAN, which covers impediments that result in high maternal and neonatal mortality rates in India. The first delay, says Hegde, relates to the earliest missteps during pregnancy, like the inability to recognize warning signs, lack of education on proper prenatal care, and avoidance of prenatal checkups. According to the latest National Family Health Survey (NFHS), only 16.7% of women in rural India have access to full antenatal care.
The second delay deals with deaths because mothers cannot reach hospitals in time. NFHS data shows that 25% of births in India still take place at home, and less than 5% of these are in the presence of skilled attendants and midwives. The third delay, meanwhile, focuses on institutional issues like the lack of medical facilities, trained professionals, medicines, and other critical inputs like unavailability of blood.
“Almost 90% of maternal deaths in India are avoidable if women receive the right advice and intervention in time,” says Hedge, “With mMitra, we’re increasing birth preparedness and complication readiness so that women have access to crucial antenatal and postnatal information.”
The mMitra service, among other female health workers, works with Accredited Social Health Activists (ASHAs) posted in clinics of government as well as private hospitals, who enroll pregnant women for the call service during their first checkup visits. ASHAs are a relatively new cadre of female community health workers instituted in 2005 as part of the Indian government’s National Rural Health Mission, which aims at providing “accessible, affordable, and quality health care to the rural population.” ASHAs are the “first port of call” for any health-related issues of the rural population, especially women and children, and most tech-based solutions work synergistically with these activists.
Aware that ASHAs make up a huge portion of the country’s community health care providers with much influence in terms of improving maternal and neonatal health, IntraHealth International, a global health organization, launched mSakhi in India eight years ago as a job aid for these frontline health workers in rural India. Using the open-source app, health care workers register details of pregnant women, new mothers, and newborn babies in the Indian states of Uttar Pradesh, Uttarakhand, and Jharkhand. They also use the tool to educate women via audio recordings, animated images, and illustrations on prenatal, delivery, and postnatal care, breastfeeding, immunization, and nutrition — all in the local language: Hindi.
Corinne Mahoney, Director of Communications for IntraHealth International, says, “mSakhi was initially developed to help ASHAs as they provided critical pregnancy and postnatal services to their clients, but eventually evolved to cover the gamut of reproductive, maternal, newborn, child, and adolescent health, including communicable and noncommunicable diseases. The intervention was absorbed by concerned government jurisdictions in December 2018.”
Meera Negi, a 48-year-old ASHA worker in the north Indian state of Uttarakhand, has been using mSakhi for the past two years. She says that the app helps her keep track of her household visits, schedule tasks, and submit updated reports to supervisors.
“It is much more convenient to use than lugging around bulky registers and counseling flipbooks,” says Negi, “Even with reference material for creating awareness, the digitized data is more easy to absorb for expecting and new mothers instead of text-heavy reference materials and complex newborn-care checklists. The app also sends me a due list for the nearly 60 women I work with. This ensures I never miss a medical checkup or delivery date.”
Developed in 2013 to address high-risk pregnancies, CareMother is another technology-based solution to ensure safer pregnancies in rural India. It comprises of two components: a medical kit and mobile application. The medical kit has seven diagnostic devices: a heartbeat meter, glucometer, stethoscope, fetal doppler, blood pressure meter, thermometer, and urine strips. The kit is offered to health care workers for regular doorstep testing and diagnosis of pregnant women in rural India, where, as in Parad’s case, closest hospitals are miles away, and regular testing is unaffordable, even time-consuming. The test results are entered into the mobile app, which alerts the health worker of high-risk factors if present. Gynecological help is immediately sought thereafter.
Over the past six years, CareMother has worked with 389 frontline health care workers across 500 villages in India, who have conducted over 100,000 checkups using the kit, and identified 22,000 high-risk pregnancies.
“As opposed to the four prenatal tests prescribed by the Indian government for pregnant women, in rural India, many women do not undergo even a single checkup during the entire term of pregnancy,” says Gajanan Shewale, head of marketing for CareMother, “Maternal and neonatal deaths are commonplace, and in addition to the lack of access to proper health care, people simply don’t bother with tests. They believe strongly in the common saying, ‘It’s a tiger’s baby; it’ll find its way out.’ Even I was born the same way. This attitude prevents the identification of high-risk factors, increasing the possibility of maternal and neonatal deaths.”
Nanda Mate, an ASHA worker since 2009, has been using CareMother for the past four years. She says that doorstep checkups have made all the difference since most of the 500 women she has worked with did not have access to affordable health care close to home. She recounts an instance from a year ago when she visited an eight-month expectant mother for a routine checkup and found the fetal heart rate to be irregular.
“I quickly called for an ambulance, and the doctor operated on the woman immediately,” recalls Mate. “The mother delivered a healthy baby, but it was a close call. Even the doctor stated that any further delay would have endangered the mother’s life.”
Like CareMother, SaveMom Ahalya is another such solution. An antenatal care kit, Ahalya contains five specially designed gadgets: a fetal heart-rate monitor, blood pressure monitor, pulse oximeter, blood glucose monitor, and a smart scale. Ahalya is in use in the tribal regions of the Indian states of Maharashtra, Kerala, and Tamil Nadu. Through ASHA workers, the kit has been used to conduct over 22,000 checkups, which has led to the identification of 382 high-risk pregnancies since 2017. The average baby weight has increased from 4.6 lbs to 6.6 lbs, says Senthil Kumar, founder of SaveMom.
Kumar states that a major reason for maternal and neonatal deaths is that patriarchy still rules the day in rural India. For example, after noticing that malnutrition was a major concern among expecting mothers, SaveMom started distributing packets containing highly nutritious foods, such as lentils, dried fruits, and nuts. However, over time, the body weights of the women remained the same. The activists realized that women were feeding that food to their husbands and children.
“In tribal areas, owing to poverty, families can’t always afford daily meals. So even if they’re pregnant, women live off water, and save solid food for their families,” says Kumar, “Even during their eighth and ninth months of pregnancies, they keep going to the fields, where they work as laborers. With such desperate circumstances, women do not bother with proper prenatal precautions. If everything goes well during the pregnancy, good. If not, they blame it on fate, or think they must have done something to displease the gods.”
Stakeholders opine that considering the socioeconomic factors, there’s a need for a larger program aimed at women’s empowerment in India. Shewli Kumar, associate professor with the Mumbai-based Tata Institute of Social Sciences also feels that since most tech-based initiatives rely on ASHAs, technology is not viable unless problems pertaining to frontline health workers are dealt with.
“An ASHA’s job is not easy. Such workers are volunteers, not employees, and are paid a pittance. They have low levels of literacy, and are overloaded with responsibilities,” says Kumar, “Most of them don’t have mobile phones. Bringing tech to them is like saying, ‘If they don’t have bread, let them eat cake.’ Technology will have a much better impact if ASHAs are duly compensated, adequately trained, and more time and money is invested in their skill development.”
Sarita Patil, the associate program director of maternal and newborn health with Mumbai-based nongovernmental organization SNEHA, agrees. She points out that recording data in apps only adds to the responsibilities of frontline health workers, who have been mandated by the state to maintain paper-based records and registers.
“The apps lead to duplication of work,” says Patil, “Such initiatives will be much more effective if they come from the government.”
However, Mahoney feels that the purpose of tech goes beyond strengthening health workforce and improving the quality of health services for Indian families. She says ASHA workers are trained to use current technology, and that this knowledge is empowering.
“What excites us most about mSakhi is that it also contributes to greater gender equality,” says Mahoney. “The app helps ASHAs build authority, expertise, confidence, and the ability to contribute something truly life-altering — that is, better health to their communities.”
For ASHAs like Mate, meanwhile, the experience is fulfilling. Mate shares that doorstep checkups have helped her build a rapport with mothers, who have started trusting her with their most intimate medical as well as personal issues. She says, “Newborns usually cringe around strangers. But with the mothers I work with, the babies don’t cry or shy away when I hold them. It’s like they know me.”
More than three years after she lost her first child, Parad recently delivered a baby boy. Her health was being regularly monitored by an ASHA worker associated with CareMother. From no medical checkup during her first pregnancy to five during her second one, Parad says that the health care worker introduced her to many crucial precautions of which she was not previously aware.
“The ASHA started with folic acid as soon as she learned I was pregnant, and gradually, added iron and calcium to my diet. She took special care of me since I had already lost a child,” says Parad. “I’ll soon celebrate my son’s first birthday.”